Office Use Only
Rochester Institute of Technology
INSTITUTIONAL REVIEW BOARD
585-475-7673 ~ www.research.rit.edu/hsro ~ hsro@rit.edu
Signed original received: _____________
Received by: ______________________
Electronic copies received: ___________
FORM A-NTID-EXT: Request for NTID IRB Review of Human Subjects Research
For Principal Investigators NOT Affiliated with NTID
 To be completed by the investigator after reading the RIT Policy for the Protection of Human Subjects in
Research, found in the Institute Policies and Procedures Manual, Section C5.0, and on the Office of Human
Subjects Research website, http://www.rit.edu/research/hsro/process_geninfo.php.
 Submit BOTH, an electronic version to hsro@rit.edu AND the signed original of the completed Form A AND
ALL attachments (consents, instruments, tasks, etc.) to HSRO, University Services Center, Suite #2400
Project Title:
SRS Proposal # SRS Proposal # (Required if associated with a sponsored project, # assigned by SRS and available in RAPID:
Investigator’s Name:
Investigator’s Phone:
Investigator’s Email:
Project Start Date:
Date of IRB Request:
Data Collection Start Date:
If Student, Name of Faculty Supervisor:
Faculty’s Phone:
Faculty’s Email:
If Not Employed or a Student at RIT, List Name,
College & Dept. of RIT Collaborator:
RIT Collaborator’s Phone:
RIT Collaborator’s Email:
Investigator’s College and Department:
Will this project be funded externally?
Yes
No
Is the Investigator a student?
If yes, name of funding agency and proposal #:
Status of project:
Funding pending
Submitted on
Do you have a personal financial relationship with the sponsor?
Yes
No
Yes
No
Funding confirmed
If yes, please read RIT policy C4.0 – Conflict of Interest Policy Pertaining to Externally Funded Projects. Complete the Investigator’s
Financial Disclosure Form and attach it to this Form A. All information will be kept confidential.
BY MY SIGNATURE BELOW, I ATTEST TO AN UNDERSTANDING OF AND AGREE TO FOLLOW ALL
APPLICABLE RIT, SPONSOR, NEW YORK STATE, AND FEDERAL POLICIES AND LAWS RELATED TO
CONDUCTING RESEARCH WITH HUMAN SUBJECTS. If significant changes in investigative procedures are
needed during the course of this project, I agree to seek approval from the IRB prior to their implementation. I further
agree to immediately report to the IRB any adverse incidents with respect to human subjects that occur in connection
with this project.
Signature of Investigator
Date
Signature of Faculty Advisor (for Student) or RIT Collaborator (for External Investigator)
Date
Signature of Department Chair or Supervisor
Date
Complete the attached Research Protocol Outline and attach to this cover form with other required attachments.
Attachments required for all projects:
Project Abstract
Human Subjects Research (HSR) Completion Report. Create an account at (https://www.citiprogram.org/)
Training information at http://www.rit.edu/research/hsro/training
Attachments required where applicable:
Informed Consent Materials
Cover letter to subjects and/or parents or guardians
Questionnaire or survey
External site IRB approval
Relevant Grant Application(s)
Other
Letter of Support from School Principal
Rev. 08.27.2015
Page 1 of 6
NTID IRB Form A EXT
Research Protocol Outline
 The NTID Institutional Review Board (IRB) categorizes Human Subjects Research into three Risk Types
(Exempt, No Greater than Minimal Risk, and Greater than Minimal Risk, defined at the end of this form).
The IRB makes the final determination of risk type.
 Please complete this entire form (1 through 10 below). ENTER A RESPONSE FOR EVERY QUESTION. If a
question does not apply to your project, please enter “N/A”. Leaving questions blank may result in the form
being returned to you for completion before it is reviewed by the IRB.
 Underlined terms are defined at the end of this form.
FOR ALL PROJECTS, please complete 1-10 below.
1)
If you believe your project qualifies for Exemption, which exemption number(s) apply?
(Note: The IRB makes the final determination of Exemption)
2.
Describe the research problem(s) your project addresses.
3.
Describe the criteria and subject selection process for your project. Include the number of subjects and
characteristics of the subject population (age and health status). Include the following:
a) How will you recruit subjects?
b) Identify criteria for inclusion or exclusion of any subpopulation.
c) Describe how you will gather data from human subjects.
4.
Will you include children in your research?
Yes
No
If children are to be included, provide a plan that addresses the following:
a) Rationale for selecting or excluding a specific range of children,
b) Description of the expertise of the personnel for dealing with children at the ages included,
c) Description of the appropriateness of the facilities,
d) Inclusion of sufficient numbers of children to ensure meaningful data.
5.
Describe expected benefits to subjects and/or knowledge to be gained from your project.
6.
Describe the potential risks to subjects:
a) Are the risks physical, psychological, social, legal or other?
b) Assess their likelihood and seriousness to subjects.
c) Discuss the potential benefits of the research to the subjects and others.
d) Discuss why the risks to subjects are reasonable in relation to the anticipated benefits to subjects and
others, or in relation to the importance of the knowledge to be gained as a result of the proposed research.
e) Describe the planned procedures for protecting against or minimizing potential risks, including risks to
confidentiality, and assess their likely effectiveness.
f) Where appropriate, describe plans for ensuring necessary medical or professional intervention in the
event of adverse effects to the subjects.
g) Describe any legal or other risks of this project to you, the PI, or to the university (RIT).
7.
Describe the data collection process.
a) Will the data collected from human subjects be anonymous?
Yes
No
b) Will the data collected from human subjects be kept confidential?
Yes
No
Describe your procedures for providing anonymity or confidentiality.
Rev. 08.27.2015
Page 2 of 6
NTID IRB Form A EXT
c) What is the time required of each subject? Will participation involve class time or
out-of-class time?
8.
Does your project require informed consent? (See the definition and explanation in the pages that follow.)
Yes
No
If yes, describe:
a) How will you obtain consent?
b) Who will seek it?
c) What is the nature of information to be provided to prospective subjects?
d) How will you document consent?
9.
Has or will this research be conducted at another university or site other than RIT?
Yes
No
If yes, describe location.
If you are conducting this research at another university or college as well as at NTID/RIT, please attach a
copy of your request to that university or college’s IRB, and a copy of their approval of your research.
Even if your research will be conducted solely at NTID/RIT, your project must be reviewed and approved by
your university or college IRB prior to submission of your request to the NTID IRB.
10. Please attach a copy of all additional materials (Consents, protocol, scripts,
instruments, tasks, etc.- everything a subject does or sees) to this application.
If your project is approved for conduct at NTID/RIT, you must agree to the following conditions:
a) To adhere to the purpose and procedures of the project as approved by NTID/RIT and to restrict the use
of data gathered in cooperation with annual quarterly status reports until the project is completed.
b) To provide the chair of the NTID IRB with one copy of all publications, including dissertations, reports,
articles, and papers, describing the completed project.
c) To acknowledge the cooperation of NTID/RIT in any published report of the project.
d) To give permission for NTID/RIT to cite the ongoing or completed project in its own publications, with
credit to you.
Further, you need to agree to the following:
a) To comply with the Family Educational Rights and Privacy Act and amendments thereto.
b) To comply with federal regulations for the protection of human subjects.
c) To report only anonymous data, so no information can be traced directly or by inference to a specific
student, family members of the student, or former school attended.
d) If student identification by name, social security number, or other means is necessary for bringing data
together on a specific student, to remove this identification as soon as the data have been assembled, and
under no condition permit this identification to be shared with other parties.
e) To destroy all materials gathered that contain personally identifiable information after the purposes for
which the material was gathered have been completed.
Rev. 08.27.2015
Page 3 of 6
NTID IRB Form A EXT
Human Subjects Research - Definitions
Is your project a research activity?
The ED Regulations for the Protection of Human Subjects, Title 34, Code of Federal Regulations, Part 97, define
research as “a systematic investigation, including research, development, testing and evaluation, designed to
develop or contribute to generalizable knowledge.” If an activity follows a deliberate plan whose purpose is to
develop or contribute to generalizable knowledge, such as an exploratory study of the collection of data to test a
hypothesis, it is research. Activities which meet this definition constitute research whether or not they are
conducted or supported under a program which is considered research for other purposes. For example, some
demonstration and service programs may include research activities.
Does your research involve human subjects?
The regulations define human subject as “a living individual about whom an investigator (whether professional or
student) conducting research obtains (1) data through intervention or interaction with the individual, or (2)
identifiable private information.” (1) If an activity involves obtaining information about a living person by
manipulating that person or that person’s environment, as might occur when a new instructional technique is
tested, or by communicating or interacting with the individual, as occurs with surveys and interviews, the definition
of human subject is met. (2) If an activity involves obtaining private information about a living person in such a
way that the information can be linked to that individual (the identity of the subject is or may be readily determined
by the investigator or associated with the information), the definition of human subject is met. [Private information
includes information about behavior that occurs in a context in which an individual can reasonably expect that no
observation or recording is taking place, and information which has been provided for specific purposes by an
individual and which the individual can reasonably expect will not be made public (for example, a school health
record).]
Population Sample
 Describe the proposed involvement of human subjects in your project.
 Describe the characteristics of the subject population, including their anticipated number, age range, and
health status.
 Identify the criteria for inclusion or exclusion of any subpopulation.
 Explain the rationale for the involvement of special classes of subjects.
Sources of Materials
 Identify the sources of research material to be obtained from individually identifiable living human subjects
in the form of specimens, records, or data.
 Indicate whether the material or data will be obtained specifically for research purposes or whether use will
be made of existing specimens, records, or data.
Definition of a Child, and Use of Children in Research
Children are defined as persons who have not attained the legal age for consent to treatments or procedures
involved in the research, under the applicable law or jurisdiction in which the research will be conducted. In New
York State, a person age 18 is considered an adult and can provide consent without parental permission. However,
some students at RIT are under age 18. To use children (individuals under the age of 18 years) in research, you
must first obtain the permission of the parent(s) and then obtain assent from the child.
Risks
As with any activity, there is potential for harm in the social and behavioral sciences – from inconvenience or
embarrassment to stigma or legal or economic consequences. Typically, however, in these sciences both the
potential harms and the risks of them are minimal and not of the type routinely being assessed in biomedical
research. Much of the risk relates to disclosure of the identity of human subjects or the information they provide;
thus, considerable effort in these sciences is devoted to safeguarding subjects’ privacy and the confidentiality of the
data they provide even when the information has no or minimal potential for harm.
Minimal risk means that the probability and magnitude of harm or discomfort anticipated in the research are not
greater in and of themselves than those ordinarily encountered in daily life or during the performance of routine
Rev. 08.27.2015
Page 4 of 6
NTID IRB Form A EXT
physical or psychological examinations or tests. “Risk” refers to a probability that some harm will occur. “Harm”
refers to a specific outcome(s) or event(s) – and can be inconvenience, physical, psychological, social, economic, or
legal in nature. If human subjects are exposed to a degree of harm roughly equivalent to what one would expect in
the course of daily life or in the course of routine tests and examinations, then “minimal risk” applies.
Anonymity
Anonymity offers the best insurance that disclosure of subjects’ responses will not occur. Research data that is
anonymous contains no information that would link the data to the individual who provided the information.
Confidentiality
Confidentiality refers to (a) identifiable data (some information about a person that would permit others to identify
the specific person, such as a non-anonymous survey, notes or a videotape of the person) and (b) agreements about
how those data are to be handled in keeping with respondents’ interest in controlling the access of others to
information about themselves. The two critical elements of this definition of confidentiality indicate the critical role
of informed consent, which states how the researcher will control access to the data and secures the respondent’s
agreement to participate under these conditions.
Informed Consent
Informed consent is a process by which individuals learn about a study – the substantive issue investigated,
participation demands (including time expenditure, types of activities), participant rights (voluntariness,
confidentiality), risks, benefits, costs/compensation, contacts if further questions arise, etc. There are multiple ways
to convey these elements of consent: by written document, oral presentation with script, oral presentation without
script. In addition, there are various ways to document consent: written signature of the participant, written
indication of participant’s study identification number, oral recording of consent, oral consent documented by the
investigator. In addition, sometimes it is important to obtain separately consent for the use of photographs or
videotaped images. The consent documents in the next few pages exemplify different ways to obtain consent,
including:
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Written consent with written documentation by participant.
a)
formal style (for study involving mothers and children)
b)
informal style
c)
formal style for at-risk population
Written consent with written indication of participant’s study identification number.
Written consent without documentation (for no/minimal risk survey studies).
Oral presentation with script with oral consent documented by the investigator.
Oral presentation with script without documentation (includes contact card).
Oral presentation without script without documentation (provides rationale for request for waiver of written
documentation and indicates what will be said).
Written consent with written documentation by participant for use of photos.
Rev. 08.27.2015
Page 5 of 6
NTID IRB Form A EXT
Types of Human Subjects Research
Exempt
Research activities in which the only involvement of human subjects will be in one or more of the following six
categories of exemptions are not covered by the regulations:
(1)
Research conducted in established or commonly accepted educational settings, involving
normal educational practices, such as (a) research on regular and special education instructional strategies, or
(b) research on the effectiveness of or the comparison among instructional techniques, curricula, or classroom
management methods.
(2)
Research involving the use of educational tests (cognitive, diagnostic, aptitude, achievement), survey
procedures, interview procedures or observation of public behavior, unless: (a) information obtained is
recorded in such a manner that human subjects can be identified, directly or through identifiers linked to the
subjects; and (b) any disclosure of the human subjects’ responses outside the research could reasonably place
the subjects at risk of criminal or civil liability or be damaging to the subjects’ financial standing,
employability, or reputation. If the subjects are children, this exemption applies only to research involving
educational tests or observations of public behavior when the investigator(s) do not participate in the
activities being observed. [Children are defined as persons who have not attained the legal age for consent to
treatments or procedures involved in the research, under the applicable law or jurisdiction in which the
research will be conducted.]
(3)
Research involving the use of educational tests (cognitive, diagnostic, aptitude, achievement), survey
procedures, interview procedures or observation of public behavior that is not exempt under section (2)
above, if the human subjects are elected or appointed public officials or candidates for public office; or
federal statute(s) require(s) without exception that the confidentiality of the personally identifiable
information will be maintained throughout the research and thereafter.
(4)
Research involving the collection or study of existing data, documents, records, pathological specimens, or
diagnostic specimens, if these sources are publicly available or if the information is recorded by the
investigator in a manner that subjects cannot be identified, directly or through identifiers linked to the
subjects.
(5)
Research and demonstration projects which are conducted by or subject to the approval of department or
agency heads, and which are designed to study, evaluate, or otherwise examine: (a) public benefit or service
programs; (b) procedures for obtaining benefits or services under those programs; (c) possible changes in or
alternatives to those programs or procedures; or (d) possible changes in methods or levels of payment for
benefits or services under those programs.
(6)
Taste and food quality evaluation and consumer acceptance studies, (a) if wholesome foods without additives
are consumed or (b) if a food is consumed that contains a food ingredient at or below the level and for a use
found to be safe, or agricultural chemical or environmental contaminant at or below the level found to be
safe, by the Food and Drug Administration or approved by the Environmental Protection Agency or the Food
Safety and Inspection Service of the US Department of Agriculture.
No Greater than Minimal Risk – The probability and magnitude of harm or discomfort anticipated in the
research is no greater than those ordinarily encountered in daily life or in the performance of routine physical and
psychological examinations or tests.
Greater than Minimal Risk – The probability and magnitude of harm or discomfort anticipated in the research is
greater than those ordinarily encountered in daily life or in the performance of routine physical and psychological
examinations or tests.
Rev. 08.27.2015
Page 6 of 6
NTID IRB Form A EXT